HEMOSTASIS

COAGULATION / THROMBUS STABILIZATION

XII XIIa

XI XIa
Endothelial Injury Tissue Injury
(Intrinsic Pathway) (Extrinsic Pathway)
IX IXa PF-3
VIII Ca++ VIIa VII

X Xa PF-3
V Ca++

Prothrombin (II) THROMBIN (IIa)

XIII XIIIa

Fibrinogen Fibrin Cross-Linked

Monomer Fibrin
 HEMOSTASIS
ANTICOAGULATION / THROMBOLYSIS
Xa, XIIa, Xia, IXa Va, VIIIa

Antithrombin
III Activated
Protein C
THROMBIN
Heparin Protein C
Thrombomodulin
Fibronectin
Urokinase
tPA
Endothelial Cell Platelet Fibrinogen Endothelial Cell
Aggregation Plasminogen Plasmin

Fibrin
strands
Fibrinogen
Fibrin Split
Products Fibrin
monomer
XIIIa
BLEEDING DISORDERS

 Coagulation factor
abnormalities
 Platelet abnormalities
 Blood vessel abnormalities
 THROMBOSIS
PREDISPOSING FACTORS
(VIRCHOW’S TRIAD) 1856

Alteration of the vascular endothelium

Alteration of blood flow

Alteration of the blood components

THROMBOSIS
VENOUS
VENOUS EMBOLI
VENOUS EMBOLI
Superficial Phlebitis: clotting of blood in superficial
veins (varicose veins). This is not dangerous and
typically a self limiting process.

Patients are treated with NSAID’s for pain control

and anti-inflammatory benefit. Also moist heat or
ice packs may help with comfort.
Migrating Phlebitis: although phlebitis is not
dangerous and only requires symptomatic care,
patients must be advised to monitor for evidence
of propagation of clot up the thigh towards the
groin. The patient may notice erythema and/or
pain moving up the leg.

In such a case venous Doppler's are repeated and

if the clot has migrated towards the sapheno-
femoral junction, the patient is treated as though
+ for DVT with systemic anticoagulation.
Venous Stasis:

 Long Haul Travel – “Economy class syndrome”

Velocity of venous blood decreases by 2/3 in the seated

position (1950’s) 1

1. Ferrari E et al. Travel as a Risk Factor for Venous Thromboembolic Disease A Case-Control Study. Chest. 1999; 115 (2):
The conclusion was that “long duration” air travel
increased risk of VTE in travelers who had other risk
factors for VTE already present.

** Immobility during the flight strongly increased the

risk for pulmonary embolism in this group.

The reality is immobility is a modifiable risk factor, and

thus patients who have other risk factors for VTE
should be encouraged to increase mobility during
flight.

Paganin F et. Al. Venous Thromboembolism in passengers following a 12 hour flight: a case-control study. Aviation Space &
Environmental Medicine. 2003; 74 (12): 1277-80.
 Is it just air travel that puts us at risk, or do other
forms of travel also carry risk for VTE?

In the VTE group, there were 39 patients who had a

history of recent travel.

Means of travel: Train  2 patients

Airplane  9 patients
Automobile  28 patients
** Immobility related to travel increases risk for VTE
whether travel is by air, train, or car.

Ferrari E et al. Travel as a Risk Factor for Venous Thromboembolic Disease A Case-Control Study. Chest. 1999; 115 (2): 440-444
 What can we do to make our patient’s safer?
Travelers flying at least 8 hours were randomized to fly
while wearing class I graduated compression stockings
vs flying without stockings.
12 passengers developed DVT.
*Although 2 patients in the compression stocking group
developed superficial phlebitis in varicose veins,
None of the compression group developed DVT!!
Scurr JH et al. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. The Lancet. 2001; 357
(9267): 1485-89.
American College of Chest Physicians Recommendations

Long Distance Travel:

1. Avoidance of constrictive clothing around the lower
extremities or waist
2. Frequent calf muscle contraction
3. Maintain adequate hydration
4. Use of graduated compression stockings (15-30 mm Hg)
5. For those with other risk factors who are felt to be high risk,
a single dose low molecular weight heparin injected prior
to departure

Antithrombotic and Thrombolytic Therapy 8th edition, ACCP Guidelines